Flu Vaccine Work Group. Laurie Fish, RN, BSN, CIC Infection Prevention Indiana University Health System

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1 Flu Vaccine Work Group Laurie Fish, RN, BSN, CIC Infection Prevention Indiana University Health System

2 Hospital members of the Indianapolis Coalition for Patient Safety have chosen to unite in an effort to require flu vaccination for healthcare workers to continue making Indianapolis a safe place to receive healthcare.

3 Flu Vaccine Work Group Membership Laurie Fish IU Health Chair Becky O Connor - Community Connie Brandes - St Francis Christia Hicks Wishard Debbie McGuire IU Health Debra Peetz - Wishard Diana Greathouse VA Diane Jones St Vincent Doug Webb, MD IU Health Jeffrey Bowman, MD St Vincent Steve Wintermeyer, MD- IUPUI Health Services Julie Conrad Wishard LeeAnn Cox IU School Med Mary Kinney - VA Mary Robbins-Nierste - Wishard Monica Vitale St Vincent Nora Cerins St Francis Orson Mason IU Health Julie Painter Community Terri Garner Wishard Theda Watson St Vincent

4 Flu Vaccine Work Group Goals: Reduce Hospital Acquired Flu One standard of practice for healthcare workforce vaccination Readiness for NHSN required HCP influenza vaccination reporting in 2013 Process: Formed work group Developed comparative table of hospital policies and vaccination rates Finalized Coalition policy using St Francis Policy as a template Drafted Coalition CEO/CMO Commitment Letter Developed Implementation Plan template with resource materials CEO/CMO sign Commitment Letter Begin Implementation January 2012 Measurement: Percent of Coalition hospitals implementing the policy by August An increase in flu vaccination rates from baseline to >95% by Feb.1, 2013.

5 Influenza Policy Highlights Annual Flu Vaccine required for entire workforce (all staff, owned & non-owned physician practices, vendors in clinical areas, students, residents, volunteers, etc.) Same standard with employed and non employed HCP Administration period: Usually October through March; Deadline for vaccination is December 15 th. Medical exemptions for those unable to accept vaccine (follows CDC Standards) Religious exemptions not addressed however most facilities are allowing for religious exemption due to legal risk. Hospital determines how to handle workforce exempted from receiving vaccine (wear mask, minimal to no patient contact, do nothing, etc.) Most hospitals in Indianapolis are not requiring the unvaccinated to wear a mask Non-compliance with Policy: Follow current hospital process for noncompliance with any policy

6 Affiliated Universities Policy review included leaders within universities within the Indianapolis area IUPUI Health Services was included in the team Comment from university leaders concern that students could be restricted from clinical due to the cost of vaccine IUPUI provides vaccination at no cost Most facilities have a process to manage vaccination of students (at a low cost)

7 Implementation Timeline Determine leadership commitment to program Form Flu Team Develop policy Q4 Q1 Q2 Q3 Q4 Address unions, students and vendors Address issue with medical staff Plan how to execute consequences for non compliance Place vaccine order Develop plan to administer vaccine Revise consent Develop exemption process and forms Develop communication and education Develop internal intranet site Develop process to meet reporting requirements Educate and communicate to leaders and then all HCP Vaccinate-Consider fun activities to engage HCP Routine reporting Find and fix problems Celebrate and recognize best practices Identify lessons learned and incorporate into program

8 Key strategies Do not reinvent the wheel and listened to those that have gone before Invited Barnes Jewish to present on their success and opened the presentation to all hospitals Quickly reached consensus on basics and allowed flexibility with areas of varied views Consequences Management of unvaccinated

9 Tools Available from ICPS Policy CEO Commitment Letter Medical Exemption Request Form Implementation Guide Sample presentations for IU Health and St Francis Hospital specific tools such as frequently asked questions.

10 Measurement and CMS Mandatory Reporting Revised protocol to be released in August 26, 2012 One time data entry at facility level Data elements 5 vaccination status categories (numerator) 3 HCP categories (denominator) Reporting to begin in Flu Season 2013 reporting will include January through March 2014 and beyond will include October March

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